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APPENDIX A

REQUEST FOR STATEMENT OF QUALIFICATIONS FFA/STRTP/ISFC SERVICES

REQUIRED FORMS

List of Required Forms

FORM NO. FORM TITLE

1 PROSPECTIVE CONTRACTOR’S ORGANIZATION QUESTIONNAIRE/AFFIDAVIT

2 CERTIFICATION OF NO CONFLICT OF INTEREST

3 PROSPECTIVE CONTRACTOR’S EQUAL EMPLOYMENT OPPORTUNITY CERTIFICATION

4 FAMILIARITY WITH THE COUNTY LOBBYIST ORDINANCE CERTIFICATION

5 PROSPECTIVE CONTRACTOR’S LIST OF CONTRACTS

6 PROSPECTIVE CONTRACTOR’S LIST OF TERMINATED CONTRACTS

7 ATTESTATION OF WILLINGNESS TO CONSIDER GAIN/GROW PARTICIPANTS

8 COUNTY OF LOS ANGELES CONTRACTOR EMPLOYEE JURY SERVICE PROGRAM CERTIFICATION FORM AND APPLICATION FOR EXCEPTION

9 CHARITABLE CONTRIBUTIONS CERTIFICATION

10 OFFER TO PERFORM ALL REQUIRED SERVICES AND ACCEPTANCE OF MASTER CONTRACT TERMS AND CONDITIONS

11 PROSPECTIVE CONTRACTOR’S INVOLVEMENT IN LITIGATION AND/OR CONTRACT COMPLIANCE DIFFICULTIES

12 CERTIFICATION OF FISCAL COMPLIANCE

13 CERTIFICATION OF OWNERSHIP AND FINANCIAL INTEREST

14 REVENUE DISCLOSURES

15 CONTRACTOR’S CERTIFICATION OF COMPLIANCE WITH CHILD, SPOUSAL, AND FAMILY SUPPORT ORDERS

16 CONTRACTOR’S CERTIFICATION OF COMPLIANCE WITH ALL FEDERAL AND STATE EMPLOYMENT REPORTING REQUIREMENTS

17

18 CONTRACTOR ACKNOWLEDGMENT AND CONFIDENTIALITY AGREEMENT

INTENTIONALLY LEFT BLANK

APPENDIX A

REQUEST FOR STATEMENT OF QUALIFICATIONS FFA/STRTP/ISFC SERVICES

List of Required Forms

18(B)

REQUIRED FORMS

19

LIST OF NAMES OF CURRENT MEMBERS OF BOARD OF DIRECTORS AND OTHER AGENCIES (if applicable)

20 SERVICE DELIVERY SITES

20(B) SERVICE DELIVERY SITES – FFA-ESC

21 CONTRACTOR’S ADMINISTRATION

22 CERTIFICATION OF COMPLIANCE WITH THE COUNTY’S DEFAULTED PROPERTY TAX REDUCTION PROGRAM

23 CONFIDENTIALITY OF CRIMINAL OFFENDER RECORD INFORMATION

24 CONTRACTOR’S CERTIFICATION OF COMPLIANCE WITH BACKGROUND AND SECURITY INVESTIGATIONS

25 INTENTIONALLY LEFT BLANK

26 FEDERAL DEBARMENT AND SUSPENSION CERTIFICATION

27 CONTRACTOR’S COMPLIANCE WITH ENCRYPTION REQUIREMENTS

28 ZERO TOLERANCE HUMAN TRAFFICKING POLICY CERTIFICATION


REQUIRED FORMS - FORM 1

PROSPECTIVE CONTRACTOR’S ORGANIZATION QUESTIONNAIRE/AFFIDAVIT

1

Please complete, date and sign this form and include it in Section A of the SOQ. The person signing the form must be authorized to sign on behalf of the Contractor and to bind the applicant in a Master Contract.

Organization Name:

Address:

Organization Telephone:

Organization Contact Person(s) Telephone:

Email Addresses of Organization Contact Person(s):

THIS STATEMENT OF QUALIFICATIONS FOR FOSTER CARE PLACEMENT SERVICES IS BEING SUBMITTED FOR THE FOLLOWING PROGRAMS:



2

Foster Family Agency (FFA)

□ DCFS□ Probation□ DCFS and Probation□ FFA-Emergency Shelter Care (DCFS)

Short-Term Residential Therapeutic Programs (STRTP)

□ DCFS□ Probation□ DCFS and Probation

Intensive Services Foster Care Foster Family Agency (ISFC FFA forSerious Emotional and Behavioral Need)


Intensive Services Foster Care Foster Family Agency (ISFC FFA forSpecial Health Care Need)


1. If your organization is a non-profit corporation, state its legal name (as found in your Articles ofIncorporation) and State of incorporation:

_______________________________________________ ____________ ________ Name State Year Inc.

2. If your organization is doing business under one or more fictitious name statement DBA’s, please list allDBA’s and the County(s) of registration:

Name County of Registration Year became DBA

_____________________________________ _________________ ______________



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_____________________________________ _________________ ______________

3. Is your organization wholly or majority owned by, or a subsidiary of, another agency/non-profitcorporation? ____

If yes, Name of parent organization: __________________________________________________.

State of incorporation or registration of parent organization: ________________________________

4. Please list any other names your organization has done business as within the last five (5) years.

Name Year of Name Change

_________________________________________________________ __________________

_________________________________________________________ __________________

5. Indicate if your organization is involved in any pending acquisition/merger, including the associatedcompany name. If not applicable, so indicate below.

______________________________________________________________________________

______________________________________________________________________________

Prospective Contractor acknowledges and certifies that it meets and will comply with all of the Minimum Qualifications listed in Section 2.0 General Information, Sub-section 2.4 – Prospective Contractor’s Minimum Qualifications, of this Request for Statement of Qualifications (RFSQ), as listed below.

Check the appropriate boxes:

Yes No Sub-paragraph 2.4.1.1 Prospective Contractor must not have any substantiated non-compliance findings or outstanding Contractor Alert Reporting Database (CARD) findings related to any County, State, Federal, or out-of-state government agency that remain unresolved. The prospective Contractor must disclose any such non-compliance findings that can be construed as being unresolved in Appendix A, Required Forms, Form 11, Prospective Contractor’s Involvement in Litigation and/or Contract Compliance Difficulties.

Yes No Sub-paragraph 2.4.1.2 Prospective Contractor shall not be on “Do Not Use” or a “Hold” with an adverse status with Los Angeles County or any other county, State, or out-of-state government agency.



4

Yes No Sub-paragraph 2.4.1.3 Prospective Contractor must be licensed by the State of California Department of Social Services (CDSS) Community Care Licensing Division (CCLD) for each program it is attempting to qualify, and must provide a copy of the license for each program and each site.

2.4.1.3.1 Prospective Contractors who do not currently hold a CDSS License, must provide documentation which indicates the licensing process has been initiated. Prospective Contractors must provide a CDSS License prior to contract execution.

Yes No Sub-paragraph 2.4.1.4 Prospective Contractor must hold an approved Rate from the CDSS Foster Care Rates Bureau for each program it is attempting to qualify, and must provide a copy of their Rate Notification letter for each program and each site.

2.4.1.4.1 Prospective Contractors who do not currently hold a CDSS Rate Notification letter, must provide a CDSS Rate Notification letter prior to contract execution.

Yes No Sub-paragraph 2.4.1.5 Prospective Contractor must be organized as a 501 (c)(3) non-profit tax exempt organization or entity.

Yes No Sub-paragraph 2.4.1.6 Organizations must be in compliance with applicable laws and regulations pertaining to financial audits, including, but not limited to, the California Government Code Section 12586, the CDSS, Manual of Policies and Procedures, Division 11, Chapter 11-400, Section 11-405 et seq., and the Office of Management and Budget 2 CFR Part 200 – Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards and 2 CFR 1.100, Title 2, Part 1.

Yes No Sub-paragraph 2.4.1.7 Prospective Contractor must demonstrate fiscal viability, based on Quick Ratio, Current Ratio, Expenses to Income Ratio, and Long Term Financial Viability Test, in accordance with Generally Accepted Accounting Principles, through a review and evaluation of the organization’s financial documents.

2.4.1.7.1 Organizations responding to this RFSQ are required to submit audited financial statements and single audits reflecting the three (3) most



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recent years for which the organization was required to conduct financial and single audits. Any organization that submits fewer than three (3) audited financial statements and single audits must indicate why they were exempt from the applicable audit requirements for each year that no audit was conducted.

2.4.1.7.2 Organizations that have less than three (3) audited financial statements and single audits may be considered for contracting and may be required to submit additional documents at County’s request. Organizations that have not been required to undergo a financial and single audit under the applicable laws and regulations must submit a copy of their current and projected budgets, balance sheet, and profit and loss statement in accordance with Generally Accepted Accounting Principles (GAAP).

Prospective Contractors attempting to qualify a FFA-ESC and STRTP must meet these additional requirements:

Yes No Sub-paragraph 2.4.2.1 Prospective Contractors must provide 24/7 intake services.

Prospective Contractors attempting to qualify an FFA-ESC program must meet this additional requirement:

Yes No Sub-paragraph 2.4.3.1 Prospective Contractor must identify a minimum of one FFA-ESC Resource Family and provide proof of the Resource Family Approval.

Prospective Contractors attempting to qualify ISFC FFA programs must meet these additional requirements:

Yes No Sub-paragraph 2.4.4.1 Must have three (3) years of experience within the last five (5) years providing FFA placement services and resources .

Yes No Sub-paragraph 2.4.4.2 Must have the ability to draw down Medi-Cal funds for the purpose of providing ISFC services via Legal Entity (LE) or Mental Health Services Act (MHSA) Master Contract with County of Los Angeles Department of Mental Health (DMH).



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Yes No Sub-paragraph 2.4.4.3 Provide a copy of their organization’s LE or MHSA Agreement with DMH.

Prospective Contractor further acknowledges that if any false, misleading, incomplete, or deceptively

unresponsive statements in connection with this SOQ are made, the SOQ may be rejected. The evaluation and determination in this area shall be at the Director’s sole judgment and his/her judgment shall be final.

On behalf of _______________________________ (Contractor’s name), I __________________________ (Name of Contractor’s authorized representative), certify that the information contained in this Contractor’s Organization Questionnaire/Affidavit is true and correct to the best of my information and belief.

_________________________________________ _________________________________ Signature Internal Revenue Service

Employer Identification Number

_________________________________________ _________________________________ Title California Business License Number

_________________________________________ _________________________________ Date County WebVen Number

_________________________________________ _________________________________ Program Number(s) Attorney General Charitable Trust Number


CERTIFICATION OF NO CONFLICT OF INTEREST

The Los Angeles County Code, Section 2.180.010, provides as follows:

CONTRACTS PROHIBITED

Notwithstanding any other section of this Code, the County shall not contract with, and shall reject any SOQs submitted by, the persons or entities specified below, unless the Board of Supervisors finds that special circumstances exist which justify the approval of such contract:

1. Employees of the County or of public agencies for which the Board of Supervisors is the

governing body;

2. Profit-making firms or businesses in which employees described in number 1 serve as officers, principals, partners, or major shareholders;

3. Persons who, within the immediately preceding 12 months, came within the provisions of

number 1, and who:

a. Were employed in positions of substantial responsibility in the area of service to be performed by the contract; or

b. Participated in any way in developing the contract or its service specifications;

and

4. Profit-making firms or businesses in which the former employees, described in number 3, serve as officers, principals, partners, or major shareholders.

Contracts submitted to the Board of Supervisors for approval or ratification shall be accompanied by an assurance by the submitting department, district, or agency that the provisions of this section have not been violated. ____________________________________________________________________________

Corporation’s Legal Name ____________________________________________________________________________ Print Name and Title of Authorized Person Responsible for the Submission of the SOQ to the County _______________________________________________________________________ Signature of Authorized Person Responsible for the Submission of the SOQ to the County


EXHIBIT __

PROSPECTIVE CONTRACTOR’S EQUAL EMPLOYMENT OPPORTUNITY CERTIFICATION

____________________________________________________________________________ Company Name ____________________________________________________________________________Address ____________________________________________________________________________ Internal Revenue Service Employer Identification Number

GENERAL

In accordance with provisions of the County Code of the County of Los Angeles, the Contractor certifies and agrees that all persons employed by such firm, its affiliates, subsidiaries, or holding companies are and will be treated equally by the firm without regard to or because of race, religion, ancestry, national origin, or sex and in compliance with all anti-discrimination laws of the United States of America and the State of California. CERTIFICATION YES NO

1. Contractor has written policy statement prohibiting

discrimination in all phases of employment. ( ) ( ) 2. Contractor periodically conducts a self-analysis or

utilization analysis of its work force. ( ) ( )

3. Contractor has a system for determining if its employment

practices are discriminatory against protected groups. ( ) ( ) 4. When problem areas are identified in employment practices,

Contractor has a system for taking reasonable corrective action to include establishment of goal and/or timetables. ( ) ( )

___________________________________________ __ ______________________ Signature of Authorized Person Responsible for Date Submission of the SOQ to the County _____________________________________________________________________________

Name and Title of Authorized Person Responsible for Submission of the SOQ to the County.


FAMILIARITY WITH THE COUNTY LOBBYIST ORDINANCE CERTIFICATION

The Contractor certifies that:

1) the Contractor is familiar with the terms of the County of Los Angeles

Lobbyist Ordinance, Los Angeles Code Chapter 2.160;

2) all persons acting on behalf of the Contractor’s organization have and

will comply with it during the RFSQ process; and

3) the Contractor is not on the County’s Executive Office’s List of

Terminated Registered Lobbyists.

Print Name and Title of the Authorized Person Responsible for the Submission of the SOQ to the County

___________________________________________________________________________

Signature of the Authorized Person Responsible for the Submission of the SOQ to the County

________________________________

Date

REQUIRED FORMS – FORM 5

PROSPECTIVE CONTRACTOR’S LIST OF CONTRACTS

Contractor’s Name: _____________________________

List of all public entities for which the Contractor has provided service within the last five (5) years. Use additional sheets if necessary.

1. Name of the Entity Address Contact Person Telephone Number Email Address ( )

Name or Contract No. Number of Years / Term of Contract Type of Service Dollar Amount










PROSPECTIVE CONTRACTOR’S LIST OF TERMINATED CONTRACTS

Contractor’s Name: _____________________________

List all contracts that have been terminated within the past five (5) years.


Name or Contract No. Reason for Termination:










ATTESTATION OF WILLINGNESS TO CONSIDER GAIN/GROW PARTICIPANTS

As a threshold requirement for consideration for contract award, Contractor shall demonstrate a proven record for hiring GAIN/GROW participants or shall attest to a willingness to consider GAIN/GROW participants for any future employment opening if they meet the minimum qualifications for that opening. Contractor shall attest to a willingness to provide employed GAIN/GROW participants access to the Contractor’s employee mentoring program, if available, to assist these individuals in obtaining permanent employment and/or promotional opportunities.

To report all job openings with job requirements to obtain qualified GAIN/GROW participants as potential employment candidates, Contractor shall email: [email protected] and [email protected].

Contractors unable to meet this requirement shall not be considered for contract award.

Contractor shall complete all of the following information, sign where indicated below, and return this form with their SOQ.

A. Contractor has a proven record of hiring GAIN/GROW participants:

______YES (subject to verification by County) ______NO

B. Contractor is willing to provide DPSS with all job openings and job requirements to consider GAIN/GROW participants for any future

employment openings, if the GAIN/GROW participant meets the minimum qualifications for the opening. “Consider” means that Contractor is

willing to interview qualified GAIN/GROW participants: ______YES ______NO

C. Contractor is willing to provide employed GAIN/GROW participants access to its employee-mentoring program, if available:

______YES ______NO ______N/A (Program not available)

Contractor Organization: _________________________________________________________ Signature: __________________________________________________________________ Print Name: _________________________________________________________________ Title: ________________________________________ Date: ________________________ Phone Number: _______________________________ Email Address: _______________________________

mailto:[email protected]

mailto:[email protected]

REQUIRED FORMS – FORM 8 EXHIBIT_____

COUNTY OF LOS ANGELES CONTRACTOR EMPLOYEE JURY SERVICE PROGRAM CERTIFICATION AND APPLICATION FOR EXCEPTION

The County’s solicitation for this Invitation for Bids is subject to the County of Los Angeles Contractor Employee Jury Service Program (Program), Los Angeles County Code, Chapter 2.203. All Contractors, whether a contractor or subcontractor, must complete this form to either certify compliance or request an exception from the Program requirements. Upon review of the submitted form, the County department will determine, in its sole discretion, whether the Bidder is excepted from the Program.

Company Name:

Company Address:

City: State: Zip Code:

Telephone Number:

Solicitation For _____________________________________________ Services:

If you believe the Jury Service Program does not apply to your business, check the appropriate box in Part I (attach documentation to support your claim); or, complete Part II to certify compliance with the Program. Whether you complete Part I or Part II, please sign and date this form below. Part I: Jury Service Program is Not Applicable to My Business

My business does not meet the definition of “contractor,” as defined in the Program, as it has not received an aggregate sum of $50,000 or more in any 12-month period under one or more County contracts or subcontracts (this exception is not available if the contract itself will exceed $50,000). I understand that the exception will be lost and I must comply with the Program if my revenues from the County exceed an aggregate sum of $50,000 in any 12-month period.

My business is a small business as defined in the Program. It 1) has ten or fewer employees; and, 2) has annual gross revenues in the preceding twelve months which, if added to the annual amount of this contract, are $500,000 or less; and, 3) is not an affiliate or subsidiary of a business dominant in its field of operation, as defined below. I understand that the exception will be lost and I must comply with the Program if the number of employees in my business and my gross annual revenues exceed the above limits.

“Dominant in its field of operation” means having more than ten employees and annual gross revenues in the preceding twelve months, which, if added to the annual amount of the contract awarded, exceed $500,000.

“Affiliate or subsidiary of a business dominant in its field of operation” means a business which is at least 20 percent owned by a business dominant in its field of operation, or by partners, officers, directors, majority stockholders, or their equivalent, of a business dominant in that field of operation.

My business is subject to a Collective Bargaining Agreement (attach agreement) that expressly provides that it supersedes all provisions of the Program,

OR Part II: Certification of Compliance

My business has and adheres to a written policy that provides, on an annual basis, no less than five days of regular pay for actual jury service for full-time employees of the business who are also California residents, or my company will have and adhere to such a policy prior to award of the contract.

I declare under penalty of perjury under the laws of the State of California that the information stated above is true and correct.

Print Name: Title:

Signature: Date:

REQUIRED FORMS – FORM 9 EXHIBIT ____

CHARITABLE CONTRIBUTIONS CERTIFICATION

____________________________________________________________________________ Company Name ____________________________________________________________________________ Address ____________________________________________________________________________ Internal Revenue Service Employer Identification Number ____________________________________________________________________________ California Registry of Charitable Trusts “CT” number (if applicable) The Nonprofit Integrity Act (SB 1262, Chapter 919) added requirements to California’s Supervision of Trustees and Fundraisers for Charitable Purposes Act which regulates those receiving and raising charitable contributions. Check the Certification below that is applicable to your company.

Bidder or Contractor has examined its activities and determined that it does not now receive or raise

charitable contributions regulated under California’s Supervision of Trustees and Fundraisers for Charitable Purposes Act. If Bidder engages in activities subjecting it to those laws during the term of a County contract, it will timely comply with them and provide County a copy of its initial registration with the California State Attorney General’s Registry of Charitable Trusts when filed.

OR

Bidder or Contractor is registered with the California Registry of Charitable Trusts under the CT

number listed above and is in compliance with its registration and reporting requirements under California law. Attached is a copy of its most recent filing with the Registry of Charitable Trusts as required by Title 11 California Code of Regulations, sections 300-301 and Government Code sections 12585-12586.

___________________________________________ ____________________________ Signature of the Authorized Person responsible for Date Submission of the SOQ to the County ___________________________________________________________________________ Name and Title of the Signer (please print)


OFFER TO PERFORM ALL REQUIRED SERVICES AND

ACCEPTANCE OF MASTER CONTRACT TERMS AND CONDITIONS (Contractor’s Legal Name) hereby offers to perform foster care placement services consists of:

Foster Family Agency

Foster Family Agency – Emergency shelter Care

Short-Term Residential Therapeutic Programs

Intensive Services Foster Care for Children with Serious Emotional and Behavior Need

Intensive Services Foster Care for Children with Special Health Care Need

under all the terms and conditions specified in the Master Contract and attached Exhibits included therein.

Print Name and Title of the Principal Owner, an Officer, or Manager authorized to bind Contractor in a Contract with the County.

Authorized Signature of the Principal Owner, an Officer, or Manager authorized to bind Contractor in a Contract with the County.



Date

REQUIRED FORM – FORM 11

PROSPECTIVE CONTRACTOR’S INVOLVEMENT IN LITIGATION AND/OR CONTRACT COMPLIANCE DIFFICULTIES

(Legal Name of Agency) Please answer “YES” or “NO” to the following questions. If a “YES” answer is marked, please attach a separate sheet and explain fully the circumstances and include discussion of the potential impact on the Contractor’s ability to perform the contract’s services, if any. The County, in its own discretion, may implement procedures to validate the responses made below. The County reserves the right to declare the contract void, if false or incorrect information is submitted by the Contractor. a. Has the Prospective Contractor been involved in any litigation? Please

include past and present litigation. YES [ ] NO [ ]

b. Has anyone on the Board of Directors, or employed by the Prospective Contractor as a CEO, President, Executive Director, or other Administrative Officer currently, or within the past seven (7) years, been involved in litigation related to the administration and operation of the Prospective Contractors business as a Foster Family Agency?

YES [ ] NO [ ]

c. Are any of the Prospective Contractor’s staff members unable to be bonded? YES [ ] NO [ ]

d. Have there been unfavorable rulings by any Government funding source against the Prospective Contractor for improper activities/ conduct or contract compliance deficiencies?

YES [ ] NO [ ]

e. Has the Prospective Contractor or any members of its Board of Directors or employees ever had public or foundation funds withheld? YES [ ] NO [ ]

f. Has the Prospective Contractor or any Board members, or employees refused to participate in any fiscal audit or review requested by a government agency or funding source?

YES [ ] NO [ ]

g. Has the Prospective Contractor or any Board members, or employees been involved in any litigation involving the prospective Contractor or any principal officers thereof, in connection with any contract within the past (7) years?

YES [ ] NO [ ]

EXPLANATION (Please use a separate sheet of paper to detail any question answered yes. Please label each page with the question that was answered with a yes. You may submit additional pages as required).

Print Name and Title of the Person authorized by the Board to bind Contractor in a Contract with the County.

Authorized Signature of the Person authorized by the Board to bind Contractor in a Contract with the County.


CERTIFICATION OF FISCAL COMPLIANCE The undersigned hereby affirms that the Contractor utilizes commonly accepted accounting procedures and maintains internal controls and procedures necessary for the monitoring of any resultant contract award. A copy of the Contractor’s last three (3) independent financial auditor’s report and financial statements, a copy of the organization’s current IRS Form 941 and EDD Form DE-9 fillings plus all management letters or reports on internal accounting procedures are included in the SUBMISSION. If there have been any failures or refusals by the undersigned to complete any previous contract(s) or grant(s) or there has been performance at a level below that required by the contract resulting in unexpended contract funds, information disclosing such failures is provided.

Print Name and Title of the Principal Owner, an Officer, or Manager authorized to bind

Contractor in a Contract with the County. Authorized Signature of the Principal Owner, an Officer, or Manager authorized to bind

Contractor in a Contract with the County. Date

REQUIRED FORMS - EXHIBIT 13

CERTIFICATION OF OWNERSHIP AND FINANCIAL INTEREST

Prospective Contractor must declare if it holds a controlling interest in any other organization, or is owned or controlled by any other person or organization.

Yes_____ No_____ If yes, provide name of organization or person and the following information:

Print Name and Title Address

Telephone Number Contact Person

I declare under penalty of perjury that the foregoing Firm/Organization information is true and correct.



Date

Prospective Contractor must declare whether it has Financial Interest in any other business.

Yes_____ No_____ If yes, provide name of business:

Print Legal Name of Business Address

Telephone Number Contact Person

I declare under penalty of perjury that the foregoing Firm/Organization information is true and correct.



Date


REVENUE DISCLOSURES

Legal Name of Agency

Yes, there are commitments (please list below).

No, there are no commitments.

LIST OF COMMITMENTS/POTENTIAL COMMITMENTS

NAME OF FIRM AMOUNT TIME PERIOD TYPE OF

COMMITMENT

I declare under penalty of perjury that the foregoing is true and correct.

Print Name and Title of the Principal Owner, an officer, or manager authorized to bind Contractor in a Contract with the County.

Authorized Signature of the Principal Owner, an officer, or manager authorized to bind Contractor in a Contract with the County. Date

REQUIRED FORMS – FORM 15 EXHIBIT _____

CONTRACTOR’S CERTIFICATION OF COMPLIANCE WITH CHILD, SPOUSAL, AND FAMILY SUPPORT ORDERS

do hereby certify that our (Name of Prospective Contractor) organization complies with all orders for Child, Spousal, and Family Support and we have complied with all lawfully served wage assignments and notices of assignment. We understand that failure to implement lawfully served wage assignments or notices of assignment will constitute a default under the contract, which shall subject the contract to termination, if such default is not cured within 90 days. Failure to comply with the above requirement may be cause for debarment.

Print Name and Title of the Principal Owner, an Officer, or Manager responsible for submission of the SOQ to the County.

Signature of the Principal Owner, an Officer, or Manager responsible for submission of the SOQ to the County.

Date



Date


CONTRACTOR’S CERTIFICATION OF COMPLIANCE WITH ALL FEDERAL AND STATE EMPLOYMENT REPORTING REQUIREMENTS

do hereby certify that our (Name of Prospective Contractor)

organization complies with all Federal and State reporting requirements related to Employment Reporting Requirements for our employees.

We understand that failure to comply with Employment Reporting Requirements will constitute a default under the contract, which shall subject the contract to termination, if such default is not cured within 90 days.

Failure to comply with the above requirement may be cause for debarment.





Date

REQUIRED FORM - FORM 18 EXHIBIT ___

CONTRACTOR ACKNOWLEDGEMENT AND CONFIDENTIALITY AGREEMENT

Contractor Name ____________________________________________________

Contract No. ______________________

GENERAL INFORMATION:

The Contractor referenced above has entered into a Master Contract with the County of Los Angeles to provide certain services to the County. The County requires the Corporation to sign this Contractor Acknowledgement and Confidentiality Agreement.

CONTRACTOR ACKNOWLEDGEMENT:

Contractor understands and agrees that the Contractor employees, consultants, Outsourced Vendors, and independent contractors (Contractor’s Staff) that will provide services in the above referenced contract are Contractor’s sole responsibility. Contractor understands and agrees that Contractor’s Staff must rely exclusively upon Contractor for payment of salary and any and all other benefits payable by virtue of Contractor’s Staff’s performance of work under the above-referenced Master Contract.

Contractor understands and agrees that Contractor’s Staff are not employees of the County of Los Angeles for any purpose whatsoever and that Contractor’s Staff do not have and will not acquire any rights or benefits of any kind from the County of Los Angeles by virtue of work under the above-referenced Master Contract. Contractor understands and agrees that Contractor’s Staff will not acquire any rights or benefits from the County of Los Angeles pursuant to any agreement between any person or entity and the County of Los Angeles.

CONFIDENTIALITY AGREEMENT:

Contractor and Contractor’s Staff may be involved with work pertaining to services provided by the County of Los Angeles and, if so, Contractor and Contractor’s Staff may have access to confidential data and information pertaining to persons and/or entities receiving services from the County. In addition, Contractor and Contractor’s Staff may also have access to proprietary information supplied by other contractors doing business with the County of Los Angeles. The County has a legal obligation to protect all such confidential data and information in its possession, especially data and information concerning health, criminal, and welfare recipient records. Contractor and Contractor’s Staff understand that if they are involved in County work, the County must ensure that Contractor and Contractor’s Staff, will protect the confidentiality of such data and information. Consequently, Contractor must sign this Confidentiality Agreement as a condition of work to be provided by Contractor’s Staff for the County.

Contractor and Contractor’s Staff hereby agrees that they will not divulge to any unauthorized person any data or information obtained while performing work pursuant to the above-referenced Master Contract between Contractor and the County of Los Angeles. Contractor and Contractor’s Staff agree to forward all requests for the release of any data or information received to County’s Project Manager.

Contractor and Contractor’s Staff agree to keep confidential all health, criminal, and welfare recipient records and all data and information pertaining to persons and/or entities receiving services from the County, design concepts, algorithms, programs, formats, documentation, Contractor proprietary information and all other original materials produced, created, or provided to Contractor and Contractor’s Staff under the above-referenced Master Contract. Contractor and Contractor’s Staff agree to protect these confidential materials against disclosure to other than Contractor or County employees who have a need to know the information. Contractor and Contractor’s Staff agree that if proprietary information supplied by other County Contractors is provided to the Contractor and Contractor’s Staff during this employment, Contractor and Contractor’s Staff shall keep such information confidential.

Contractor and Contractor’s Staff agree to report any and all violations of this agreement by Contractor and Contractor’s Staff and/or by any other person of whom Contractor and Contractor’s Staff become aware.

Contractor and Contractor’s Staff acknowledge that violation of this agreement may subject Contractor and Contractor’s Staff to civil and/or criminal action and that the County of Los Angeles may seek all possible legal redress.

SIGNATURE: DATE: _____/_____/______

PRINTED NAME: __________________________________________

POSITION: _________________________________________

REQUIRED FORMS - FORM 18(B)


REQUIRED FORM – FORM 19

LIST OF NAMES OF CURRENT MEMBERS OF BOARD OF DIRECTORS AND OTHER AGENCIES (if applicable)

Legal Name of Agency: ______________________________________________________________________

FIRST NAME LAST NAME BUSINESS ADDRESS BUSINESS

PHONE NUMBER

EMAIL ADDRESS

OTHER AGENCIES*

*List the name of the other agency that the Board Member also serves on. (Please make additional copies of this form if necessary)

I declare under penalty of perjury that the foregoing is true and correct.

Print Name and Title of the Principal Owner, Officer, or Manager authorized to bind the Contractor in a Contract with the County

Authorized signature of the Principal Owner, Officer, or Manager authorized to bind the Contractor in a Contract with the County

__________________________________ Date

REQUIRED FORMS – FORM 20 EXHIBIT ___

SERVICE DELIVERY SITES

Type of program (Check one): Foster Family Agency (FFA)

Short-Term Residential Therapeutic Programs (STRTP)

Intensive Services Foster Care (ISFC)

Administrative Office/Headquarters

AGENCY NAME AGENCY CORPORATE ADDRESS AGENCY CONTACT

PERSON TELEPHONE NUMBER/

EMAIL ADDRESS

Name of FFA Director: ______________________________ Name of STRTP Administrator: _________________________________

Licensed Facilities Included in this Contract

FACILITY NAME YOUTH SERVED

(DCFS, Probation, or Dually Supervised)

FACILITY ADDRESS FACILITY MANAGER TELEPHONE NUMBER/

EMAIL ADDRESS

(Submit a separate Form 20 for each type of program, e.g. FFA, STRTP, or ISFC). Use additional sheets if necessary.

REQUIRED FORMS – FORM 20 EXHIBIT ___


Yes No Are any of the facilities listed above on County owned or County Leased property? If yes, please provide an explanation:

Yes No Do any or your agency’s Board members or employees, or members of their immediate families own any property leased or rented by your agency? If yes, please provide an explanation.

On behalf of _______________________________ (Contractor’s name), I __________________________ (Name of Contractor’s authorized representative), certify that the information contained in this Service Delivery Sites – Form #20 is true and correct to the best of my information and belief.



Date

REQUIRED FORMS – FORM 20(B) EXHIBIT ___

SERVICE DELIVERY SITES Type of program: Foster Family Agency - Emergency Shelter Care

Administrative Office/Headquarters

AGENCY NAME AGENCY CORPORATE ADDRESS AGENCY CONTACT PERSON

TELEPHONE NUMBER/ EMAIL ADDRESS

Name of FFA Director: ________________________________

Licensed Facilities Included in this Contract

FACILITY NAME YOUTH SERVED- DCFS OR PROB

FACILITY ADDRESS FACILITY MANAGER TELEPHONE NUMBER/ EMAIL ADDRESS

REQUIRED FORMS – FORM 20(B) EXHIBIT ___


Yes No Are any of the facilities listed above on County owned or County Leased property? If yes, please provide an explanation:

Yes No Do any or your agency’s Board members or employees, or members of their immediate families own any property leased or rented by your agency? If yes, please provide an explanation.

On behalf of _______________________________ (Contractor’s name), I __________________________ (Name of Contractor’s authorized representative), certify that the information contained in this Service Delivery Sites – Form #20(B) is true and correct to the best of my information and belief.



Date


EXHIBT ____

Page 1 of 2

CONTRACTOR’S ADMINISTRATION

CONTRACTOR’S NOTICES SHALL BE SENT TO CONTRACTOR’S CORPORATE ADDRESS. PLEASE ENTER YOUR ORGANIZATION’S CORPORATE ADDRESS AS

INDICATED ON THE ORGANIZATION’S CERTIFIED STATEMENT OF INFORMATION (SOI). THE DESIGNATED CONTACT PERSON(S) WILL RECEIVE ALL

CORRESPONDENCE TO THIS CONTRACT.

Organization Name: _____________________________________________

Contact Person: _____________________________________________

Title: _____________________________________________

Street Address: _____________________________________________

City, State, Zip: _____________________________________________

Telephone: _____________________________________________

Email Address: _____________________________________________

Contact Person: _____________________________________________

Title: _____________________________________________

Street Address: _____________________________________________

City, State, Zip: _____________________________________________

Telephone: _____________________________________________

Email Address: ___________________________________________________


EXHIBT ____

Page 2 of 2

CONTRACTOR’S AUTHORIZED OFFICIAL(S)

(Individuals authorized by the Board to bind Contractor in a Contract with the County)

Name: _____________________________________________

Title: _____________________________________________

Street Address: _____________________________________________

City, State, Zip: _____________________________________________

Telephone: _____________________________________________

Email Address: _____________________________________________

Name: _____________________________________________

Title: _____________________________________________

Street Address: _____________________________________________

City, State, Zip: _____________________________________________

Telephone: _____________________________________________

Email Address: ___________________________________________________

IF THERE ARE ANY CHANGES, A NEW CERTIFIED SOI MUST BE SUBMITTED TO:

DCFS Contracts Administration Division Attn: Contracts Division Manager 425 Shatto Place, Room 400 Los Angeles, CA 90020

I hereby certify that the above information is correct. If any changes occur an updated Contractor’s Administration Form and a new certified SOI will be submitted to DCFS Contracts Administration Division at the above address. __________________________________________________________________________ Print Name of Individual Authorized to Bind Contractor in a Contract with the County _________________________________________________________________________ Signature of Individual Authorized to Bind Contractor in a Contract with the County ________________________

Date

REQUIRED FORM - FORM 22 EXHIBIT ___

CERTIFICATION OF COMPLIANCE WITH THE COUNTY’S DEFAULTED PROPERTY TAX REDUCTION PROGRAM

Company Name:

Company Address:


Telephone Number: Email address:

Solicitation/Contract For ____________ Services:

The Proposer/Bidder/Contractor certifies that:

□ It is familiar with the terms of the County of Los Angeles Defaulted Property Tax Reduction

Program, Los Angeles County Code Chapter 2.206; AND

To the best of its knowledge, after a reasonable inquiry, the Proposer/Bidder/Contractor is not in default, as that term is defined in Los Angeles County Code Section 2.206.020.E, on any Los Angeles County property tax obligation; AND

The Proposer/Bidder/Contractor agrees to comply with the County’s Defaulted Property Tax Reduction Program during the term of any awarded contract.

- OR -

□ I am exempt from the County of Los Angeles Defaulted Property Tax Reduction Program, pursuant

to Los Angeles County Code Section 2.206.060, for the following reason:______________________________________________________________________________

______________________________________________________________________________

I declare under penalty of perjury under the laws of the State of California that the information stated above is true and correct.

Print Name: Title:

Signature: Date:

Date: ____________________


OPTIONAL: use if Probation youth will be served, remove if not

CONFIDENTIALITY OF CRIMINAL OFFENDER RECORD INFORMATION

Criminal Offender Record Information (CORI) is that information which is recorded as the result of an arrest, detention, or other initiation of criminal proceedings including any consequent proceedings related thereto. As an employee of _____________________ during the legitimate course of duties, you may have access to CORI. The Probation Department has a policy of protecting the confidentiality of Criminal Offender Record Information.

You are required to protect the information contained in the case files against disclosure to all individuals who do not have a right-to-know this information.

The use of any information obtained from case files or other related sources of CORI to make contacts with probationers or other relatives, or make CORI available to anyone who has no real and proper reason to have access to this information as determined solely by the Probation Department is considered a breach of confidentiality, inappropriate and unauthorized.

Any ________________ employee engaging in such activities is in violation of the Probation Department’s confidentiality policy and will be subject to appropriate disciplinary action and/or criminal action pursuant to Section 11142 of the Penal Code.

I have read and understand the Probation Department’s policy concerning the confidentiality of CORI records.

_____________________________________ (Signature)

_____________________________________ Name (Print)

_____________________________________ Title

_____________________________________ Date

Copy to be forwarded to Probation Contract Manager within five (5) business days of start of employment.

CONTRACTOR’S CERTIFICATION OF COMPLIANCE WITH BACKGROUND AND SECURITY INVESTIGATIONS

______________________________________do hereby certify that our (Name of Prospective Contractor)

organization complies with and completes all criminal clearances including arranging to receive subsequent arrest notifications and background checks on all staff, employees, independent contractors, and volunteers as well as all Subcontractors’ staff and volunteers, prior to beginning and continuing work under this contract. Such background investigation may include, but shall not limited to criminal conviction information obtained through fingerprints submitted to the California Department of Justice.

Our organization further agrees not to engage or continue to engage the employees or volunteers on contract services of any person convicted of any crime involving harm to children, or any crime involving conduct inimical to the health, morals, welfare or safety of others, including but not limited to the offenses specified in Health and Safety Code, Section 11590 (offenses requiring registration as a controlled substance offender) and those crimes listed in the Penal Code which involve murder, rape, kidnap, abduction, assault, and lewd and lascivious acts.

We understand that failure to comply with the Background and Security Investigations provisions will constitute a material breach and be considered an event of default under the contract, which shall subject the contract to termination if such default is not cured within 3 days.

In compliance with the False Claims Act (31 U.S.C. §3729-3733), I certify that all the information on this form is true and correct.

______________________________ (Signature), Title________________ Date: ___________

______________________________ (Signature), Title________________ Date: ___________

_______________________________________Print Name of authorized signer, Chief Executive Officer or Chief Financial Officer, or Authorized Treasurer or other Authorized signed of the Board of Directors

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REQUIRED FORM - FORM 24

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EXHIBIT


FEDERAL DEBARMENT AND SUSPENSION CERTIFICATION

____________________________________________________________________________ Company Name

____________________________________________________________________________Address

____________________________________________________________________________ Internal Revenue Service Employer Identification Number

This certification is required by the regulations implementing Executive Order 1259, Debarment and Suspensions, 7 CFR Part 3017, 45 CFR Part 76 and 2CFR 200.212 Part C.

Prospective Contractor certifies to the best of its knowledge and belief that its principals or affiliates or sub-contractor utilized under this contract are not:

(a) Debarred or suspended from federal financial assistance programs and activities; (b) Proposed for debarment; (c) Declared ineligible or; (d) Voluntarily excluded from participation in covered transactions by any federal

department or agency.

I declare that the information herein is true and correct and that I am authorized to represent this company.

___________________________________________ __ ______________________ Signature of the Authorized Person Responsible for Date Submission of the SOQ to the County

_____________________________________________________________________________

Name and Title of the Authorized Person Responsible for Submission of the SOQ to the County

REQUIRED FORMS- FORM 27

CONTRACTOR'S COMPLIANCE WITH ENCRYPTION REQUIREMENTS

Contractor shall provide information about its encryption practices by completing this Exhibit. By

submitting this Exhibit, Contractor certifies that it will be in compliance with Los Angeles County

Board of Supervisors Policy 5.200, Contractor Protection of Electronic County Information, at the

commencement of any contract and during the term of any contract that may be awarded pursuant

to this solicitation.

DOCUMENTAT ION

AVAILABLE

COMPLIANCE QUESTIONS

1) Will County data stored on your workstation(s) be encrypted?

2) Will County data stored on your laptop(s) be encrypted?

3) Will County data stored on removable media be encrypted?

4) Will County data be encrypted when transmitted?

5) Will Contractor maintain a copy of any

validation/attestation reports generated by its encryption

tools?

6) Will County data be stored on remote servers*?

*cloud storage, Software-as-a-Service or SaaS

Agency Name

Name of the Authorized Person Responsible for Submission of the SOQ

Authorized Person Official Title

Authorized Person Official's Signature

YES NO YES NO


ZERO TOLERANCE HUMAN TRAFFICKING POLICY CERTIFICATION

Agency Name:

Agency Address:


Telephone Number: Email address:

Solicitation/Contract for _______________________________ Services

CONTRACTOR CERTIFICATION

Los Angeles County has taken significant steps to protect victims of human trafficking by establishing a zero tolerance human trafficking policy that prohibits contractors found to have engaged in human trafficking from receiving contract awards or performing services under a County contract.

Prospective Contractor acknowledges and certifies compliance with Section 8.54 (Compliance with County’s Zero Tolerance Human Trafficking Policy) of the proposed Contract and agrees that Contractor or a member of his staff performing work under the proposed Contract will be in compliance. Prospective Contractor further acknowledges that noncompliance with the County's Zero Tolerance Human Trafficking Policy may result in rejection of any SOQ, or cancellation of any resultant Contract, at the sole judgment of the County.

I declare under penalty of perjury under the laws of the State of California that the information herein is true and correct and that I am authorized to represent this company.

Print Name: Title:

Signature: Date:

request for statement of qualifications …contracts.dcfs.lacounty.gov/uploads/103_fillable... ·...

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